Mixed-Method Nursing Research

Article

Mixed-Method Nursing Research: “A Public and Its Problems?” A Commentary on French Nursing Research

Policy, Politics, & Nursing Practice 2014, Vol. 15(1–2) 15–20 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1527154414538100 ppn.sagepub.com

Cećile Marie Dupin, RN, MSc1,2,3, Christophe Debout, CRNA, MSN, PhD1, and Monique Rothan-Tondeur, RN, ICPO, PhD2,3

Abstract Nursing in France is undergoing a transition. In 2009, the preregistration nursing education program was reformed in line with the European Bologna Process, bringing nursing education to the universities. In 2010, the French Programme Hospitalier de Recherche Infirmie`re, the first national French nursing research funding program, was launched by the French Health Ministry. Of the 149 French research proposals submitted by registered nurses in 2010 and 2011, 13 were mixed-method proposals. The registered nurse principal investigator argued for a complementary use of qualitative and quantitative methods. These trends highlight major issues regarding mixed-method and nursing research. We can reasonably assume that mixed-method research has a broad appeal for nurse scholars, particularly for the exploration of complex phenomena related to nursing. Moreover, the recent movement in the domain of nursing education and research experienced in France highlights the need for dedicated research education in the development of nursing research capacity. Keywords France, funding program, mixed-method, nursing research, research capacity, research education

Introduction Nursing research combines experience, intellectual ability, and formal systems of thought and contributes to the optimization of patient care (Polit & Beck, 2012). Nursing research and education was recently transformed in France. Nursing in France is experiencing a massive transition, from vocational to academic (Debout et al., 2012). In addition, the French government has demonstrated its commitment to nursing research by providing dedicated funding for nursing research (Dupin, Chami, Dariel, Debout, & RothanTondeur, 2013). The nature of publicly funded research in the health care sector is closely linked with the development of research (Plano Clark, 2010).

French Nursing Research: A New Agency The nursing profession in France is at a stage of transformation. In France, nursing, as a professional

discipline, is in a quest for scientific, professional, and social legitimacy (Debout, 2010). Registered nurses (RNs) have pursued advanced degrees in France (master’s and doctoral studies) but always in disciplines other than nursing, such as epidemiology, education, anthropology, and sociology (Jovic & Isambart, 2009). Nurses 1

French School of Public Health (EHESP), Rennes, France Pierre et Marie Curie University – Paris 6, Pierre Louis School of Public Health (ED 393), Paris, France 3 Institut National de la Sante´ et de la Recherche Me´dicale, Department of Epidemiology, Information Systems, and Modeling (UMR-S 707), Paris, France 2

Corresponding Author: Cećile Marie Dupin, RN, MSc, Ingeńieur de recherche, De´partement Sciences Humaines, Sociales et des Comportements de Sante´, Chaire INPES “Promotion de la Sante´” a` l’EHESP, Ecole des Hautes Etudes en Sante´ Publique (EHESP), Avenue du Professeur-León-Bernard, CS 74312, 35043 Rennes Cedex, France. Email: [email protected]

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Policy, Politics, & Nursing Practice 15(1–2)

were forced to obtain their advanced degrees in related disciplines and have struggled to develop projects that were specific to the profession. Reform aimed at integrating nursing education into higher education institutions was introduced in the French context through the Bologna Process in 2009. The Bologna Process, a European standard for nursing education, aimed to make higher education in Europe converge toward a more common system, through which the different national systems would share frameworks for bachelor’s, master’s, and doctoral levels of education (Zabalegui et al., 2006). French nursing preregistration education has experienced profound reforms following the Bologna Declaration. The main innovation has been the competency-based approach, with a competency devoted to research education. French nursing organizations lobbied actively to obtain from the government the academization of the nursing education system. The preregistration program, its development, and its validation have resulted from working groups that have included all of the relevant stakeholders, that is, professional bodies, trade unions, employers, and other health professions (Debout et al., 2012). In 2009, the first master’s-level program in clinical nursing sciences was launched, bringing advanced nursing skills into clinical practice with the integration of evidence-based practice in the syllabus. Since 2010, French public hospitals have offered scholarships to nurses to pursue doctoral studies. These processes illustrate that professional push as well as policy pull factors are essential to the achievement of policy change (Rafferty & Traynor, 2004).

Indeed, nursing research in France has experienced relative seclusion from the international community due to the limited support structures in place and the difficulty in accessing the primarily English language-based scientific community. However, the French government has demonstrated its commitment to nursing research. The French Programme Hospitalier de Recherche Infirmie`re (PHRI), the first national French nursing research funding program, was launched in 2010. Calls for research proposals were launched by the French Ministry of Health (Paris, France) in September 2009 and July 2010. The administrative guidelines outlined the purpose and value of the PHRI program, including the provision of scientific knowledge to hospital teams and decision makers to improve nursing care in health facilities and the promotion of interdisciplinary perspectives. The objective proposed by the guidelines was to encourage the development of research in the field of nursing by offering dedicated funding for RNs (Dupin et al., 2013). This initiative facilitates the development of research in the country, with dedicated public funding. This program emphasizes the production of nursing scientific knowledge within hospitals and clinical settings. Strategic priorities were specified in the call for proposals in 2010 and 2011 (Table 1). This situation contributes to the development of research, in line with international scientific nursing advances. The call for proposals, initiated by the Ministry of Health, was issued once a year starting in 2009. The research proposals were received by the French Ministry of Health, the sponsor of the PHRI. Registered nurse principal investigators (RNPIs) were

Table 1. Priorities of the Funding Program for Nursing Research. 2010

2011

Quality and safety of care Palliative care Alzheimer’s disease and related disorders Informing the patient and his entourage Prevention and detection of abuse Dependence of people and maintaining their independence

Quality and safety of care Improving professional practice Evaluation of organizations Organization and management of care Prevention and detection of abuse Impact of health policy and training Evaluation of interventions to improve practices Development and validation of new standards of care Validation of new treatment methods and practices Projects on the complementarity and subsidiarity between places of care Research on cooperation between professionals

Note. Adapted from the Ministe`re de la Sante´ et des Sports (2009, 2010).


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responsible for developing their research proposals, as explicitly mandated in the call for proposals written into the administrative guidelines, and 149 were submitted by RNPIs in 2010 and 2011. The administrative guidelines provided detailed information on the expected format and content of the submitted research proposals. The RNPIs were expected to develop their research proposals according to the call for proposals via the administrative guidelines and submit them to the funding program. Each research proposal was sent to the French Health Ministry via the executive committee of the hospital in which each RNPI worked.

Mixed-Method Nursing Research in the Funding Stream Of the 149 proposals submitted by the French RNPIs in the funding stream in 2010 and 2011, 13 were mixedmethod research proposals. Six RNs serving as principal investigators in 2010 and seven in 2011 submitted those projects. Three were men, and six were nurse managers. Four RNPIs had a master’s degree, and one was currently involved in a PhD. Eight nurses were practicing in the clinical domain, four in management, and one in nursing education. Eleven projects out of 13 were developed in teaching hospitals. Eleven French regions were represented in this sample. Mixed-method approaches can be mixed-method (in a study) or multimethod, in which each study is conducted in its entirety and the results are triangulated at the end of the phases. The submitted mixed-method research proposals were qualitatively (QUAL)-driven (N ¼ 9) and quantitatively (QUAN)-driven (N ¼ 4) sequential designs (Morse, 2003). Thus, each strand of a sequential method might explore a phenomenon from a different perspective to achieve a more global understanding of the phenomenon under study (Morse, 2003; Ostlund et al., 2011). Nine out of the 13 proposals were QUAL-driven (Morse, 2003). The RNPIs argued, as a central premise, for the previous need for initial in-depth and detailed exploration of a little researched phenomenon (Creswell et al., 2003; Polit & Beck, 2012). This QUAL dominance outlines the favoring of exploratory designs, for example, interviews analyzed using content analysis and questionnaires assessed using bivariate and multivariate statistical analyses. Four out of the 13 proposals were QUANdriven explanatory models, for example, an impact measure study followed by interviews. The RNPIs mandate complex research designs to capture complex health and human problems, aiming at producing results at different levels (Morse, 2003; Sandelowski, 2000; Twinn, 2003).

Among the research proposals, the clinical domain was the most investigated. The QUAL-driven proposals were primarily concentrated (N ¼ 7) in the clinical area. Among those projects, two were developed in oncology, one in surgery, one in cardiology, and one in mental health care. The most recurrent theme was patient education, that is, three projects out of seven. One proposal included research in management, that is, management strategies toward the improvement of quality of nursing care, and one proposal involved nursing education, that is, education for oral care in palliative units. This dominance of the clinical domain persisted in the QUAN-driven category, with three projects in the clinical field, that is, optimization and quality of care with breast cancer patients in family nursing practice facing schizophrenia; and one project in the management of palliative care units. Qualitative and quantitative methods were used to provide information regarding proficiency in hospital-based research and educational interventions.

Emergence of a Scholarship in France: Challenges in Using Mixed-Method The foundations of qualitative and quantitative paradigms are theoretically opposed, and thus, their combination might generate epistemological paradoxes (Morris & Burkett, 2011). However, the French nursing research proposals explore the possibilities of different research methods using a dialectical stance justified by the RNPIs in terms of the complementarity of the different methods. This position assumes that all paradigms have something to offer to better understand a phenomenon and produce new and useful scientific knowledge (Greene & Caracelli, 2003). In the mixed-method research proposals submitted for funding, no evident research question has been raised. The research designs were shaped by the research objectives. Concurrently, forming the research question in mixed-method studies is a back-and-forth, interactive and evolving process (Onwuegbuzie & Leech, 2006). The 13 RNPIs argued for the need for more than one type of data and two or more distinct phases for the efficiency of nursing knowledge development (Polit & Beck, 2012; Wazqar, 2011). Today, the value of mixed-method studies is affirmed in nursing research, where they are presented as complementary and alternative to the traditional qualitative and quantitative approaches (Burke Johnson & Onwuegbuzie, 2004; Polit & Beck, 2012).This methodological trend is also known as a “movement,” or the “third paradigm for research,” within the community engaged in mixed-method research designs (Creswell & Garret, 2008; Denscombe, 2008). This field is obviously emergent in the research proposals


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submitted to the first two editions of the French nursing research funding program (PHRI). French RNPIs found themselves in the research continuum through an epistemological congruence (Morse, 2003; Niglas, 2010) represented by their methodological choice and the rationale for those scientific positions. This trend could soon be subjected to the same development experienced in the international nursing scientific community and face the issues experienced in the wider community.

Future Public Investment: What are the Possible Strategies? The nursing research capacity in France is moving forward, thanks to dedicated funding. Simultaneously, the French situation highlights the need for an applicable strategy, because research activity without goals or a plan of action could fail to yield any real prospect of consolidation or impact on nursing practice (Tierney, 2005). Health research public policy in France should aim to empower nursing research and nursing research training, which is critical for using evidence in clinical practice (Johansson et al., 2010). The domains of research and undergraduate education in France are finally moving in line with the developments observed at the European level. The development of research capacity in France would provide internally supportive factors, such as research training fellowships, posts in higher education, and research training for clinical staff, as well as externally supportive factors, such as additional funding for research training, institutional support structures and infrastructure, and dedicated time to pursue research and dedicated funding (Rafferty & Traynor, 2004; Smith, 2007; Tierney, 1998), and nursing research would benefit from cultural factors such as a naturalized reciprocity between practice and research (Dupin et al., 2014). The organization of education should enable nurses to have access to appropriate levels to provide them with the skills needed for research (PhD and postdoctoral; European Health Committee, 1996; Tierney, 1998). Foremost, to promote quality research, it is necessary to establish nursing research units within departments of higher learning, where qualified nurse researchers may carry out long-term research on a continuous basis (Tierney, 1998) so that the skills and knowledge necessary to conduct research can be acquired. Research education should address research method training as a central matter for capacity development. Today, France still suffers from a lack of doctoral-level programs dedicated to nursing (Debout et al., 2012; Dupin et al., 2013). The lack of an institutionalized nursing discipline in France contributes to the gap in the production of scientific nursing knowledge (Eymard, 2012).

Concurrently, skills in the qualitative and quantitative research are needed. A major issue in mixed-method research is the difficulty in conducting mixed-method studies as a novice researcher (Collins & O’Cathain, 2009; Polit & Beck, 2012). Effective educational strategies should equip French nurse scholars with the skills and competencies for conducting mixed-method research to utilize both quantitative and qualitative techniques. Having a positive attitude toward both techniques could place nurses in a better position to ensure that qualitative research informs the quantitative portion of studies and vice versa (Onwuegbuzie & Leech, 2005a).

Conclusions Of the 149 research proposals submitted for funding in 2010 and 2011, only 13 were mixed-method studies. The nursing research proposals that were received through the PHRI funding program might have been influenced by the requirements specified in the administrative guidelines, which favor interventional quantitative and exogenous research (Dupin et al., 2013). In the context of public health research, one possibility is to promote designs according to research objective (exploratory and confirmatory) instead of subdividing them using the quantitative/qualitative dichotomy (Onwuegbuzie & Leech, 2005b). Nursing research in France has been “living in seclusion” (Debout, 2010) due to a lack of organizational support and dedicated funding. The problems experienced by French nurse researchers are public rather than private. In the community, variations and inconsistencies might appear in the process of knowledge acquisition. Using institutional and educational support, mixed-method nursing research in France could be strengthened and sufficiently empowered for nurse scholars to choose to focus, in the future, on methodological issues, research processes, or philosophical assumptions (Creswell & Garret, 2008). Ethical Considerations The confidentiality and anonymity of the research teams were respected. The files were coded, and the data were entered on an office computer that was protected with an access code in a locked office. The research proposals were studied with the authorization of the French Health Ministry.

Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this


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article: This survey was supported by the French Ministry of Health Program for Nursing Research (Programme Hospitalier de Recherche Infirmie`re – PHRI, 2010, PHRI 1001). The funder has no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript.

Acknowledgments The authors wish to thank the French Ministry of Health, the Doctoral Network of the French School of Public Health, and members of the European Academy of Nursing Science for their encouragement and Laure Alary for previous comments on the manuscript.

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Author Biographies Cećile Marie Dupin is a registered nurse, MPolSc, currently involved in a PhD exploring French nursing research from a sociological and epistemological standpoint. Christophe Debout is a certified registered nurse anesthetist, PhD, professor and Head of the Nursing Sciences Department in the French School of Public Health. Monique Rothan-Tondeur is a registered nurse, PhD, and was the Head of the Committee of the funding program for hospital nursing research in 2010 and 2011.
